Can J Anesth/J Can Anesth (2010) 57:694–703
DOI 10.1007/s12630-010-9315-3
REVIEW ARTICLE/BRIEF REVIEW
Lumbar spinal stenosis: a brief review of the nonsurgical
management
La sténose du canal lombaire: une courte synthèse de la
prise en charge non chirurgicale
De Q. H. Tran, MD • Silvia Duong, BScPhm •
Roderick J. Finlayson, MD
Received: 15 January 2010 / Accepted: 12 April 2010 / Published online: 29 April 2010
 Canadian Anesthesiologists’ Society 2010
Abstract
Purpose The purpose of this brief narrative review is to
summarize the evidence derived from randomized con-
trolled trials pertaining to the nonsurgical treatment of
lumbar spinal stenosis (LSS).
Source The MEDLINE (January 1950 to the fourth week
of January 2010) and EMBASE (January 1980 to 2009,
week 53) databases, the MESH term ‘‘spinal stenosis’’, and
the key words, ‘‘vertebral canal stenosis’’ and ‘‘neurogenic
claudication’’, were searched. Results were limited to
randomized controlled trials (RCTs) conducted on human
subjects, written in English, and published in peer-
reviewed journals. Only RCTs pertaining to nonsurgical
treatment were considered. Studies comparing conserva-
tive and surgical management or different surgical
techniques were not included in the review.
Principal findings The search criteria yielded 13 RCTs.
The average enrolment was 54 subjects per study. Blinded
assessment and sample size justification were provided in
85% and 39% of RCTs, respectively.
The available evidence suggests that parenteral calcitonin,
but not intranasal calcitonin, can transiently decrease pain
in patients with LSS. In the setting of epidural blocks, local
anesthetics can improve pain and function, but the benefits
seem short-lived. The available evidence does not support
the addition of steroids to local anesthetic agents. Based on
D. Q. H. Tran, MD (&)
R. J. Finlayson, MD
Department of Anesthesia,Montreal General Hospital, McGill
University, 1650 Ave Cedar D10-144, Montreal, QC H3G 1A4,
Canada
e-mail: de_tran@hotmail.com
S. Duong, BScPhm
Faculty of Pharmacy, University of Toronto, Toronto,
ON, Canada
123
the limited evidence, passive physical therapy seems to
provide minimal benefits in LSS. The optimal regimen for
active physiotherapy remains unknown. Although benefits
have been reported with gabapentin, limaprost, methylco-
balamin, and epidural adhesiolysis, further trials are
required to validate these findings.
Conclusions Because of their variable quality, published
RCTs can provide only limited evidence to formulate rec-
ommendations pertaining to the nonsurgical treatment of
LSS. In this narrative review, no study was excluded based
on factors such as sample size justification, statistical
power, blinding, definition of intervention allocation, or
clinical outcomes. This aspect may represent a limitation
as it may serve to overemphasize evidence derived from
‘‘weaker’’ trials. Further well-designed RCTs are
warranted.
Résumé
Objectif L’objectif de cette courte synthe`se narrative
consiste à re´sumer les donne´es probantes provenant des
essais comparatifs randomise´s se rapportant au traitement
non chirurgical de la ste´nose du canal lombaire (SCL).
Source Les bases de donne´es MEDLINE (de janvier
1950 à la quatrie`me semaine de janvier 2010) et EMBASE
(de janvier 1980 à 2009, semaine 53), le terme MESH
« spinal stenosis » et les mots cle´s « vertebral canal
stenosis » et « neurogenic claudication » ont e´te´ utilise´s.
Les re´sultats ont e´te´ limite´s à des essais comparatifs
randomise´s (ECR) mene´s chez des sujets humains, re´dige´s
en anglais et publie´s dans des publications e´value´es par les
pairs. Seuls les ECR se rapportant au traitement non
chirurgical ont e´te´ conside´re´s. Les e´tudes comparant les
approches conservatrice et chirurgicale ou les e´tudes
comparant diffe´rentes techniques chirurgicales ont e´te´
exclues de cette synthe`se.
Nonsurgical management of lumbar spinal stenosis
Résultats principaux Les crite`res de recherche ont
permis d’identifier 13 ECR. Le taux de participation moyen
e´tait de 54 sujets par e´tude. L’e´valuation en aveugle et la
justification de la taille des e´chantillons e´taient fournies
dans 85 % et 39 % des ECR, respectivement.
Les donne´es probantes disponibles sugge`rent que la
calcitonine administre´e par voie parente´rale, et non par
voie intranasale, peut re´duire de manie`re transitoire la
douleur chez les patients atteints de SCL. Dans le cadre
d’une anesthe´sie e´pidurale, les anesthe´siques locaux
peuvent re´duire la douleur et ame´liorer la capacite´
fonctionnelle, mais leurs bienfaits semblent eˆtre de courte
dure´e. Les donne´es probantes disponibles n’appuient pas
l’ajout de ste´roı¨des aux anesthe´siques locaux. Il existe des
donne´es limite´es en faveur d’avantages minimes de la
physiothe´rapie passive en cas de SCL. Le programme
optimal de physiothe´rapie active demeure inconnu. Bien
que certains avantages aient e´te´ note´s lors de l’utilisation
de la gabapentine, du limaprost, de la me´thylcobalamine et
de la lyse d’adhe´rences e´pidurales, d’autres essais sont
ne´cessaires afin de valider les re´sultats.
Conclusions En raison de leur qualite´ variable, les ECR
publie´es ne peuvent offrir qu’une quantite´ limite´e de
donne´es probantes en vue de formuler des recommandations
se rapportant au traitement non chirurgical d’une SCL.
Dans le cadre de cette synthe`se narrative, aucune e´tude n’a
e´te´ exclue en raison de facteurs tels que la justification de
la taille des e´chantillons, la puissance statistique, l’insu, la
de´finition de l’attribution d’intervention ou les re´sultats
cliniques. Cet aspect peut constituer une limite puisqu’il
peut eˆtre utilise´ pour amplifier l’importance des donne´es
provenant d’essais « plus faibles » . D’autres ECR bien
conçus sont ne´cessaires.
First described more than one hundred years ago,1 lumbar
spinal stenosis (LSS) is characterized by narrowing of the
spinal canal with encroachment on neural structures by the
surrounding soft tissues and bones.2 Although LSS can be
congenital, it is more often the result of degenerative
phenomena, such as spondylolisthesis and age-related
changes (loss of intervertebral disc height, disc bulging,
infolding of ligamentum flavum, facet joint osteoarthritis/
hypertrophy/ osteophyte/ cystic formation).3 Lumbar spinal
stenosis is the most common indication for back surgery in
geriatric patients.4-6 In 1994, it was estimated that one
billion dollars was spent annually in the United States
alone to provide surgical decompression for LSS.7 How-
ever, in elderly patients, surgery is not devoid of
complications.4 Thus conservative management is often
tried first, and includes physical therapy, pharmacotherapy,
695
as well as ancillary measures, such as manipulation, brac-
ing, traction, and electrical stimulation.8 Epidural injection
of steroids can also be used for pain control.9
The last five years have seen the publication of ten
review articles of variable quality pertaining to LSS.10-18 In
all cases, recommendations stemmed from the combined
results of non-randomized as well as randomized con-
trolled trials (RCTs), and scrutiny of the reference lists
reveals the omission of RCTs (Appendix). Furthermore,
30% of the available trials were published in the last two
years (2008-2009) and, to date, they have not been incor-
porated in a review article.19-22 Accordingly, using a
comprehensive literature search for level 1 evidence
(RCTs), we decided to produce a brief and up-to-date
narrative review focusing exclusively on the nonsurgical
management of LSS.
Search strategy and article selection criteria
The literature search for this review was conducted during
the fourth week of January 2010, using the MEDLINE
(January 1950 to the fourth week of January 2010) and
EMBASE (January 1980 to 2009, week 53) databases.
The MESH term, ‘‘spinal stenosis’’, as well as the key
words, ‘‘vertebral canal stenosis’’ and ‘‘neurogenic clau-
dication’’, were searched. Results were limited to RCTs
pertaining to nonsurgical treatment conducted on human
subjects, written in English, and published in peer-
reviewed journals. We excluded trials that investigated the
impact of interventions on parameters measured in vitro
(nerve root blood flow) without assessing the clinical
response of patients. Randomized controlled trials pub-
lished in the form of abstracts or correspondence were also
discarded. Furthermore, the RCTs needed to deal exclu-
sively with LSS. We excluded trials that enrolled patients
suffering from LSS and other spine pathologies (such as
radiculopathy due to disc herniation) and that indiscrimi-
nately pooled results from all subjects. However, studies
providing data specific to LSS were considered in this
review. For trials that included both a randomized cohort
and a concurrent observational cohort of patients who
declined to undergo randomization, only results pertaining
to the former were kept. Studies comparing conservative
and surgical management or different surgical techniques
were not included in the review.
After selecting the initial articles, we examined the
reference lists as well as our personal files for additional
material. No RCTs were excluded based on factors such as
definition of intervention allocation or primary and sec-
ondary (clinical) outcomes. However, non-randomized
studies, observational case reports, and cohort studies were
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696 D. Q. H. Tran et al.

excluded to avoid potential biases introduced by institu-
tional practices.
Findings
Our initial search criteria yielded 14 RCTs. One RCT was
excluded because the authors did not conduct statistical
tests to compare the results.23 Six of the remaining 13
RCTs studied pharmacological treatment (Table 1), and
five investigated neuraxial blocks or epiduroscopic adhes-
iolysis (Table 2). Physical therapy was addressed by three
studies (Table 3). As per this classification, the sum of
these RCTs (14) exceeds the total found (13), because one
trial compared both epidural blocks and physiotherapy to
control treatment.22
Overall, the quality of the RCTs was variable. The
average enrolment was 54 subjects per study. Blinded
assessment and sample size justification were provided in
85% and 39% of RCTs, respectively. The duration of
symptomatic LSS prior to enrolment was provided in 77%
of studies and varied from 12.0 weeks to 11.4 years. Pain
was the most commonly studied endpoint (69% of trials);
patient follow-up varied from 4.0 weeks to 2.5 years.

Table 1 Pharmacological treatment trials related to lumbar spinal stenosis

Authors Blinded Description Number Primary Outcomes and Duration Main Findings
(year) Assessment/ of of Follow-Up
Sample Size Patients/
justification Groups

Eskola Y/N SC calcitonin (100 units) vs 39/2 Pain (VAS), walking distance, Compared with baseline, greater
et al.25 placebo every other day for 4 jumping time until 12 wks after decreases in static and dynamic
(1992) wks start of treatment pain scores in calcitonin for
duration of 3 months
Crossover after 2-month washout No differences in walking distance
period and jumping times
Podichetty Y/N Daily nasal calcitonin (400 units) 47/2 Pain (VAS), walking distance, No differences
et al.26 vs placebo for 6 wks walking time, physical and
(2004) emotional functional
assessment (SF-36) until 6 wks
after start of treatment
Tafazal Y/N Daily nasal calcitonin (200 units) 37/2 Pain (VAS), walking distance, No differences
et al.27 vs placebo for 3 wks ODI, LBOS until 4 wks after
(2007) start of treatment
Yaksi N/N 4-month course of gabapentin 55/2 Pain (VAS), walking distance, Gabapentin: greater walking
et al.31 (starting daily dose of 900 mg; sensory deficits, motor deficits distance (2nd, 3rd, and 4th
(2007) weekly increments of 300 mg until 4 months after start of months), lower pain scores (3rd
until maximum of 2,400 mg) treatment and 4th months), and lower
combined with conservative incidence of sensory deficits
management (physical therapy, (4th month)
corset, NSAIDs) vs
conservative management
alone
Matsudaira N/N Limaprost (15 lg po tid) vs 66/2 SF-36 at 8 wks after start of Limaprost: greater improvements
et al.21 etodolac (400 mg po bid) for 8 treatment in SF-36 subscales of physical
(2009) wks function, role physical, bodily
pain, vitality, and mental health
Limaprost: greater walking
distance, subjective
improvement, satisfaction, and
improvement in leg numbness
Waikakul Y/N 6-month course of 152/2 Pain, limitations of spinal motion, Methylcobalamin: greater walking
et al.35 methylcobalamin (0.5 mg po walking distance, neurological distance at 6, 12, and 18 months
(2000) tid) vs control exam (sensorimotor functions, No other intergroup differences
DTR, SLR) until 2 yrs after
start of treatment
bid = bis in die (twice daily); DTR = deep tendon reflexes; LBOS = Low Back Outcome Score; N = no; NSAIDs = non-steroidal anti-
inflammatory drugs; ODI = Oswestry Disability Index; po = per os; SC = subcutaneous; SF-36 = Medical Outcomes Study Short Form-36;
SLR = straight leg raise test; tid = ter in die (three times a day); VAS = visual analogue scale; wk = week; Y = yes

123
Nonsurgical management of lumbar spinal stenosis 697

Table 2 Trials pertaining to epidural block and adhesiolysis for lumbar spinal stenosis
Authors Blinded Description Number of Patients/ Primary Outcomes/ Main Findings
(year) Assessment/ Groups Duration of Follow-Up
Sample Size
justification

Fukusaki Y/N Series of 2 non fluoroscopy-guided 53/3 Walking distance until Both treatment groups:
et al.37 epidural injections: NS vs 1% M 3 months after greater walking
(1998) 8 mL vs 1% M 8 mL and treatment distance at 1 wk
methylprednisolone 40 mg No intergroup differences
at 1 and 3 months
No differences between 2
treatment groups
Koc et al.22 Y/N Control vs physiotherapy (2-wk 29/3 Pain (VAS), walk test, Epidural: greater
(2009) course) vs fluoroscopy-guided sit-to-stand test, improvement in VAS,
interlaminal epidural (0.5% B weight-carrying test, RMDI, and NHP than
15 mg and triamcinolone 60 mg) RMDI, NHP until control at 2 wks
6 months after No differences between 2
treatment treatment groups
Cuckler Y/Y Interlaminar epidural with 1 % P 37/2 Success (75 % No difference in short
et al.45 5 mL and NS vs improvement in pain term (24 h) and long
(1985) methylprednisolone 80 mg compared with term (13-30 months)
baseline) until 13- success
30 months after
treatment
Manchikanti Y/Y Fluoroscopy-guided caudal injection: 40/2 (Preliminary Pain (NRS) until 1 yr No intergroup differences
et al.19 0.5% L 10 mL vs 0.5% L 9 mL results of ongoing after treatment in NRS, ODI,
(2008) and betamethasone 6 mg trial aiming to employment status,
(injections could be repeated based recruit total of 120 opioid intake at 3, 6,
on clinical response) patients) and 12 months
Manchikanti Y/Y Fluroscopy-guided caudal (catheter 50/2 (Preliminary Pain (NRS) until 1 yr Adhesiolysis: lower NRS
et al.20 threaded to S3 and injected with results of ongoing after treatment and ODI at 3, 6, and
(2009) 5 mL 2%, 6 mL NS and 6 mg trial aiming to 12 months
betamethasone) vs adhesiolysis recruit total of 120 No differences in
(catheter threaded to level of patients) employment status and
defect, adhesiolysis performed and opioid intake
catheter injected with 2% 5 mL,
10% 6 mL sodium chloride
solution and betamethasone 6 mg)
(treatments could be repeated
based on clinical response)
B = bupivacaine; L = lidocaine; M = mepivacaine; N = no; NHP = Nottingham Health Profile; NRS = Numeric Rating Scale; NS = normal
saline; ODI = Oswestry Disability Index; P = procaine; RMDI = Roland Morris Disability Index; wk = week; Y = yes; Yr = year

Pharmacological therapy
Calcitonin
Calcitonin has received considerable interest in the man-
agement of LSS because of its direct analgesic properties
(through release of ß-endorphin).24 Alternately, calcitonin
can decrease the vascular supply to the bone by lowering
its metabolic activity, thus allowing more blood to reach
the compromised neural tissues.25 To date, four RCTs have
investigated the use of calcitonin in LSS.
In 1992, Eskola et al.25 conducted a double-blind,
crossover RCT on 39 patients suffering from LSS. The
subjects initially received a subcutaneous injection of
calcitonin or placebo every other day for four weeks. After a
two-month washout period, the alternate solution was
administered for another four weeks. When comparing with
baseline levels, these authors observed that statistically
greater decreases in static and dynamic pain scores were
seen in the calcitonin group for up to three months irre-
spective of the order of administration. However, increases
in walking distance and jumping time did not survive the
crossover. Furthermore, at one year, none of the two groups
experienced residual benefits.25 In 2004, Podichetty et al.26
recruited 47 patients and compared a six-week regimen of
intranasal calcitonin with placebo. At six weeks, no dif-
ferences in pain, walking distance, walking time, and
physical or emotional function were found between the

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698 D. Q. H. Tran et al.

Table 3 Trials pertaining to physical therapy for lumbar spinal stenosis

Authors Blinded Description Number Primary Outcome and Duration Main Findings
(year) Assessment/ of of Follow-Up
Sample Size Patients/
justification Groups

Koc Y/N Control vs PT (2-wk course of hot pack, 29/3 Pain (VAS), walk test, sit-to- PT: no differences
et al.22 TENS, and US application) vs stand test, weight-carrying compared with control
(2009) fluoroscopy-guided interlaminal epidural test, RMDI, NHP until Epidural: greater
(B and triamcinolone) 6 months after treatment improvement in VAS,
RMDI, and NHP than
in Control at 2 wks
Whitman Y/Y Twice weekly, 6-wk regimen: lumbar 55/2 GRC until 1 yr after start of Gp II: higher perceived
et al.46 flexion exercise/ walking program/ US treatment recovery (GRC C 3) at
(2006) (Gp I) vs manual therapy/ exercise/ 6 wks
walking program (Gp II) No difference in
perceived recovery at
1 yr
No differences in ODI,
NPRS, SSS
Satisfaction Subscale,
walking distance
Pua Y/Y Twice weekly, 6-wk regimen: cycling vs 42/3 ODI until 6 wks after start of No differences in ODI,
et al.47 treadmill ambulation with body weight treatment RMDI, VAS, perceived
(2007) support benefit and ability to
walk C 800 m
B = bupivacaine; Gp = group; GRC = global rating of change; N = no; NHP = Nottingham Health Profile; NPRS = numeric pain rating
scale; ODI = Oswestry Disability Index; PT = physiotherapy; RMDI = Roland Morris Disability Index; SSS = spinal stenosis scale;
TENS = transcutaneous electrical nerve stimulation; US = ultrasound; VAS = visual analogue scale; wk = week

treatment and control groups. Subsequently, in 37 subjects
with LSS, Tafazal et al.27 compared a four-week regimen of
intranasal calcitonin with placebo. Again, no intergroup
differences were noted in terms of pain and walking dis-
tance. The Oswestry Disability Index (ODI) and Low Back
Outcome Score were also similar between the two groups.
Gabapentin
Voltage-sensitive calcium and sodium channels accumu-
late at sites of axonal injury.28 By binding to the a2 delta
subunit of these channels, gabapentin has been thought to
modulate neural transmission and provide analgesia.29,30
In 2007, Yaksi et al.31 randomized 55 patients with LSS
to a four-month regimen of gabapentin combined with
conservative management or conservative management
alone. The latter included physical therapy (lumbar flexion,
pelvic traction, and strengthening of abdominal muscles),
the use of a lumbosacral corset, and pharmacological
treatment with non-steroidal anti-inflammatory drugs
(NSAIDs). Throughout the trial, these authors observed a
greater walking distance in the gabapentin group. Fur-
thermore, pain scores were also significantly lower in the
latter at the end of the third and fourth months (3.6 ± 2.2
vs 4.8 ± 2.2; P = 0.039; and 2.9 ± 2.6 vs 4.7 ± 2.2,
respectively; P = 0.006). After four months, a greater
reduction in sensory deficits was seen with gabapentin
compared with conservative management (decrease of
28.6% vs 7.4%, respectively; P = 0.04).31
Limaprost
The pathogenesis of LSS may be multifactorial. Mechan-
ical compression of the spinal cord can lead to a decrease
in the vascular supply of neural tissues.32 Limaprost, an
alprostadil (prostaglandin E1) analogue, possesses vasodi-
latory, antiplatelet, and cytoprotective properties.33
In 66 patients, Matsudaira et al.21 compared limaprost
with etidolac, a NSAID. After eight weeks, subjects
receiving limaprost displayed better scores pertaining to
Standard Form-36 (SF-36) subscales of physical function,
physical role, bodily pain, vitality, and mental health.
Furthermore, greater improvements were also noted in
terms of walking distance, leg numbness, and patient sat-
isfaction. However, the two groups did not differ in terms
of low back and leg pain.21
Methylcobalamin
Since high doses of vitamins, such as B6, have been used in
nerve entrapment syndromes,34 Waikakul et al.35 set out to
investigate the role of methylcobalamin, a methyl-vitamin

123
Nonsurgical management of lumbar spinal stenosis
B12, in LSS. These authors randomized 152 patients to a
six-month regimen of methylcobalamin or control. All
subjects also received patient education, core strengthening
exercises, physiotherapy, oral analgesics, NSAIDs, muscle
relaxants, and supplemental vitamins. During the entire
study period (two years), there were no intergroup differ-
ences observed in terms of pain, limitations of motion,
straight leg raise test, or neurological findings. However,
patients receiving methylcobalamin experienced greater
improvement in ambulation at six, 12, and 18 months.35
Interpretation
The available evidence suggests that parenteral calcitonin,
but not intranasal calcitonin, can lead to transient benefits
(B three months) in patients with LSS. Although gaba-
pentin, limaprost, and methylcobalamin have been shown
to improve parameters, such as analgesia, walking distance,
or sensory deficits, further trials are required to validate
these findings because of the small number of RCTs
involved.
Epidural blockade and adhesiolysis
Epidural blockade
In LSS, pain may be due to transient ischemia of the cauda
equine.36 Thus, epidural injection of local anesthetics is
commonly used to provide sympathetic blockade and
vasodilation, thereby increasing blood flow to neural tis-
sues.37 Furthermore local anesthetic agents can also exert
beneficial effects by curtailing pain-induced neuronal sen-
sitization and release of neurotransmitters involved in pain
pathways.38-41 Alternately, administration of corticoste-
roids in the epidural space is thought to reduce
inflammatory edema of the injured nerve root,42 decrease
sensitization of the dorsal horn neurons,43 and suppress the
transmission of nociceptive C fibres.44 In clinical practice,
both agents are often combined.37
To date, two RCTs have compared epidural injection of
local anesthetics with placebo or conservative management
(NSAIDs, physiotherapy). In 53 patients suffering from
LSS, Fukusaki et al.37 performed a series of two non
fluoroscopy-guided interlaminar epidural injections and
randomized the injectate to saline, local anesthetic, and
local anesthetic with steroid (methyprednisolone). Com-
pared with placebo, these authors observed a greater
walking distance at one week in both treatment groups
(87-92 ± 58-66 vs 23 ± 19 m; P \ 0.05). However, this
beneficial effect did not persist, as no differences were
found at one and three months. Interestingly, steroids did
not add any clinical benefits.37 In 2009, Koc et al.22
699
randomized 29 subjects with LSS to control, physiotherapy
(two-week course of hot pack, transcutaneous electrical
nerve stimulation, and ultrasound application), or fluoros-
copy-guided interlaminar epidural injection (bupivacaine
and triamcinolone). In addition, all patients received a
six-month home-based exercise program of muscle
stretching/ strengthening and a two-week course of dic-
lofenac. Intergroup analysis revealed that, compared with
controls, epidural injection resulted in a greater improve-
ment in pain intensity, Roland Morris Disability Index, and
Nottingham Health Profile at two weeks.22
In addition to Fukusaki et al.’s study,37 two other RCTs
have investigated the role of steroids in epidural blockade.
In 1985, Cuckler et al.45 randomized 37 patients to an
epidural injection containing procaine combined with sal-
ine or methylprednisolone. Success was defined as a 75%
improvement compared with baseline. No difference in
success rates was found between the two groups at the 24
hr (17.7-25.0%) and the 13-30 month follow-ups (10.5-
25%). In 2007, Manchikanti et al. set out to recruit 120
subjects with LSS. The intended goal was to compare
fluoroscopy-guided caudal injection of local anesthetic
(lidocaine) with or without corticosteroid (betamethasone).
In 2008, these authors published their preliminary findings
in 40 patients (20 per group). Manchikanti et al.19 observed
that the addition of betamethasone to lidocaine did not
improve analgesia, employment status, ODI scores, and
opioid intake after three, six, and twelve months.
Epidural adhesiolysis
In 2006, Manchikanti et al. set out to recruit 120 subjects
with LSS. The intended goal was to compare fluoroscopy-
guided caudal injection of lidocaine and betamethasone
with percutaneous epidural adhesiolysis. In 2009, these
authors published their preliminary findings in 50 patients
(25 per group). Manchikanti et al.20 observed that patients
receiving adhesiolysis exhibited lower scores for pain and
ODI at three, six, and twelve months. Furthermore, after
adhesiolysis, the average duration of relief was also longer
for patients with back pain (12.3 ± 10.9 vs 3.2 ±
3.7 weeks; P \ 0.05) and leg pain (12.5 ± 11.0 vs 3.1 ±
3.8 weeks; P \ 0.05). However, no intergroup differences
in opioid intake and employment status were found.
Interpretation
Although epidural injection of local anesthetics has been
shown to improve pain and function in LSS, these benefits
seem short-lived (\ one month). The available evidence
does not support the addition of steroids to local anesthetic
agents. Despite promising early results, further studies are
required to validate the use of epidural adhesiolysis in LSS.
123
700
Physical therapy
Passive physical therapy has been studied in one trial. Koc
et al.22 randomized 29 subjects with LSS to control,
physiotherapy (two-week course of hot pack, transcutane-
ous electrical nerve stimulation, and ultrasound
application), or epidural injection (bupivacaine and triam-
cinolone). In addition, all patients received a six-month
home-based exercise program of muscle stretching and
strengthening as well as a two-week course of diclofenac.
No difference was found between the physiotherapy and
control groups. In contrast, as previously stated, compared
with controls, epidural injection resulted in a greater
improvement in pain intensity, Roland Morris Disability
Index, and Nottingham Health Profile at two weeks.22
To date, two RCTs have attempted to determine the
optimal regimen for (active) physical therapy. In 2006,
Whitman et al.46 randomized 55 patients with LSS to two
six-week physiotherapy regimens. The first group (Group I)
received lumbar flexion exercises, a progressive treadmill
ambulation program, and subtherapeutic pulsed ultrasound.
The second group (Group II) received manual physical
therapy (spine, pelvis, and lower extremities), exercises
(designed to improve mobility, strength and coordination),
and a body weight-supported treadmill ambulation pro-
gram. In addition, all subjects received a home exercise
program, and they were asked to take a daily walk. Whit-
man et al.46 defined perceived recovery as a global rating
of change score C 3. At six weeks, Group II presented a
higher rate of perceived recovery (79 vs 41% of patients;
P = 0.0015). However, no statistical differences were
found at one year and on long-term telephone follow-up
(27.4-29.0 months). Furthermore, throughout the study
period, the authors reported no intergroup differences in
terms of pain, walking distance, ODI, and Spinal Stenosis
Scale Satisfaction Subscale scores.46 In 2007, Pua et al.47
randomized 42 patients to a six-week physiotherapy regi-
men of cycling or treadmill ambulation with body weight
support. All subjects also received a home exercise pro-
gram of flexion/ neural mobilization exercises. At three and
six weeks, no differences were found in terms of disability
(ODI, Roland Morris Disability Index) and pain.47
Interpretation
The limited evidence available suggests that passive
physical therapy provides minimal benefits. The optimal
regimen for active physiotherapy remains unknown.
Although the combination of manual therapy/ exercise/
body weight-supported ambulation results in a higher rate
of perceived recovery than the combination of flexion
123
D. Q. H. Tran et al.
exercise/ progressive treadmill ambulation/ ultrasound,
these benefits did not persist beyond six weeks and did not
translate into an improvement of objective indices. Fur-
thermore, no differences were found between cycling and
treadmill ambulation with body weight support.
Discussion
In terms of pharmacological treatment, the available evi-
dence suggests that parenteral calcitonin, but not intranasal
calcitonin, can transiently decrease pain in patients with
LSS. Although benefits have been reported with gabapen-
tin, limaprost, and methylcobalamin, further trials are
required to validate these findings. In the setting of epidural
blocks, local anesthetic agents can improve pain and
function, but the benefits seem short-lived. The available
evidence does not support the addition of steroids to local
anesthetics. Despite promising results, further studies are
required to validate the use of epidural adhesiolysis for
patients with LSS. Based on the limited evidence available,
passive physical therapy seems to provide minimal benefits
in LSS. The optimal regimen for active physiotherapy
remains unknown.
A critical survey of the available RCTs can provide an
effective tool to establish focused recommendations per-
taining to the nonsurgical treatment of LSS. For instance,
in this review, no evidence was found to support the use of
epidural steroid injection (ESI). This is stark contrast with
recently published review articles. Using the pooled results
of case series, observational trials and RCTs, 70% of the
latter recommended ESI. Furthermore, despite the unclear
benefits and limited efficacy associated with active and
passive physiotherapy, respectively, 90% of recent reviews
advocated the use of physiotherapy. Alarmingly, a device
that can be potentially harmful (through muscle decondi-
tioning), such as a stabilization brace, was recommended
for occasional use by 40% of reviews despite the absence
of RCTs (Appendix). Since our review article incorporated
RCTs missing from previous publications, new and
promising therapeutic modalities (limaprost, methylcobal-
amin, and epidural adhesiolysis) have also been identified.
Although the limited evidence available does not permit
their clinical implementation at this time, further investi-
gation is certainly warranted.
For practical reasons, a decision was taken to limit this
review to RCTs published in the English language.
Although such a restriction may constitute a methodolog-
ical limitation, we believe that its impact on the paper’s
conclusions is small, since expansion of our search criteria
(using the same databases and time periods) to languages
Nonsurgical management of lumbar spinal stenosis 701

Table 4 Nonsurgical management strategies warranting further clinical investigation

Pharmacotherapy • Efficacy of acetaminophen, NSAIDs, selective COX 2 inhibitors, and opioids
• Confirmatory trials for gabapentin, methylcobalamin, and limaprost
• Pregabalin vs gabapentin
Physical therapy • Optimal regimen for active physical therapy
Interventional Treatment • Palpation- vs fluoroscopy-guided interlaminal epidural injection of LA
• Fluoroscopy-guided interlaminar vs transforaminal vs caudal epidural injection of LA
• Confirmatory trials for epiduroscopic adhesiolysis
Multimodal Treatment • Efficacy of multimodal treatment
• Best combination for multimodal management
COX = cyclooxygenase; LA = local anesthetic agent; NSAID = non-steroidal anti-inflammatory drug

other than English yielded only three additional RCTs.48-50
No attempt was made in this review to produce a meta-
analysis. In our view, given the wide array of modalities
used for pharmacological and physical therapy, patient
enrolment would have been insufficient to support a sys-
tematic pooling of data. For interventional treatments, the
heterogeneity in techniques (palpation- vs fluoroscopy-
guided epidural block vs adhesiolysis) would have consti-
tuted an obstacle. In this narrative review, no RCT was
excluded based on factors such as sample size justification,
statistical power, blinding, definition of intervention allo-
cation, or clinical outcomes. This may represent a limitation
to our article, as it may serve to overemphasize evidence
derived from ‘‘weaker’’ RCTs. Most importantly, if trials
lacked sample size justification, provided limited enrol-
ment, and found no difference between study groups, we
cannot exclude the possibility that they were inadequately
powered to answer the question they sought to investigate.
Despite current best evidence, many issues regarding
nonsurgical modalities remain unresolved and, thus,
require elucidation through well-designed and meticulously
conducted RCTs (Table 4). Future trials should use sample
size justification and blinded assessment. Furthermore, the
duration of LSS prior to enrolment and the length of fol-
low-up should be rigorously controlled. For trials
investigating interventional treatment, evidence-based
standardized conservative management should be imple-
mented in the control group. Lastly, most studies have
focused thus far on single or dual therapeutic modalities—
the role of multimodal therapy warrants investigation.
Appendix
See Table 5

Table 5 Recently published reviews of lumbar spinal stenosis

Authors Focused Restricted Inclusion of All Contemporary RCTs Pertaining Recommended Nonsurgical Treatment
(reference on to RCTs Contemporary RCTs* to Nonsurgical Treatment Not
number) Treatment Pertaining to Nonsurgical Included in Review (reference
(year) Treatment numbers)

Katz et al.2 N N N 25, 26, 27, 31, 35, 46, 47 Stabilization brace (occasional),
(2008) PT (core-strengthening exercises),
pharmacotherapy (acetaminophen,
NSAIS, mild opioid), ESI
Kim N N N 25, 26, 35, 37, 45 Rest, restricted movement, stabilization
et al.10 brace (occasional), PT (massage, heat,
(2005) cold, US, TENS, core-strengthening
exercises), acupuncture, exercises (bike,
treadmill, aquatic ambulation), balance
training, patient education, biofeedback,
relaxation training, pharmacotherapy
(acetaminophen, aspirin, NSAID,
tramadol, opioid, muscle relaxant,
antidepressant, anticonvulsant), ESI

123
702 D. Q. H. Tran et al.

Table 5 continued
Authors Focused Restricted Inclusion of All Contemporary RCTs Pertaining Recommended Nonsurgical Treatment
(reference on to RCTs Contemporary RCTs* to Nonsurgical Treatment Not
number) Treatment Pertaining to Nonsurgical Included in Review (reference
(year) Treatment numbers)

Yuan Y N N 26, 35, 37 Rest, PT (flexion-based exercises), aquatic

et al.11 training, exercise, patient education
(2005) (posture, ADL), pharmacotherapy
(aspirin, NSAID, muscle relaxant,
antidepressant, oral corticosteroid,
calcitonin), ESI
Atlas Y N N 25, 35, 37, 45 PT, exercise, patient education, analgesics
et al.12
(2006)
Babb N N N 25, 26, 35, 37, 45 Stabilization brace (occasional), PT, weight
et al.13 loss program (if overweight), exercises
(2006) (bicycle, aquatic therapy, inclined
treadmill), pharmacotherapy (NSAID,
oral steroid), ESI
Englund14 N N N 25, 35, 37, 46 PT (core-strengthening exercises), exercises
(2007) (bicycle, aquatic therapy, inclined
treadmill), pharmacotherapy
(acetaminophen, NSAID, anticonvulsant,
oral corticosteroid)
Chad15 N N N 25, 26, 35, 37, 45, 46 Stabilization brace (occasional), PT (back/
(2007) leg lengthening exercises, US, TENS),
weight loss program (if overweight),
exercises (bicycle, walking),
pharmacotherapy (NSAID, muscle
relaxant), ESI
Markman N N N 25, 27, 31, 35, 37, 45, 46, 47 No clear recommendation
et al.16
(2008)
Rahman N N N 25, 27, 31, 35, 37, 45, 46, 47 PT (back/ leg lengthening exercises,
et al.17 mobility training, US, TENS),
(2008) pharmacotherapy (NSAID, muscle
relaxant), ESI
Aliabadi N N N 19, 25, 26, 27, 31, 35, 45, 47 PT (manual PT, body weight-supported
et al.18 treadmill).
(2009) No clear recommendation pertaining to ESI
ADL = activities of daily living; ESI = epidural steroid injection; N = no; NSAID = non-steroidal anti-inflammatory drug; PT = physio-
therapy; RCT = randomized controlled trial; TENS = transcutaneous electrical nerve stimulation; US = ultrasound; Y = yes
* A contemporary RCT is defined as a RCT published no later than the year prior to the publication of the review article

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